- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $2,778.87 / $3,955.04
| Facility | | $2,090.73 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.50 / $126.23 / $182.02
| Professional | | $71.50 | $126.23 | $182.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.65 / $156.34 / $250.09
| Professional | | $81.65 | $156.34 | $250.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.94 / $198.97 / $350.48
| Professional | | $113.94 | $198.97 | $350.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.52 / $241.56 / $326.33
| Professional | | $141.52 | $241.56 | $326.33 |